Heart Failure Pharmacotherapy and Long-Term Outcomes After Extracorporeal Membrane Oxygenation: A Nationwide Real-World Cohort Study

Objective: We examined prescription trends and associations between post-discharge heart failure (HF) guideline-directed medical therapy (GDMT) and long-term outcomes in patients with cardiogenic extracorporeal membrane oxygenation (ECMO), a population with limited evidence on long-term management. Methods: This nationwide retrospective observational cohort used Taiwan's real-world National Health Insurance Research Database. Adults undergoing cardiogenic ECMO during 2011-2023 who survived at least 6 months after discharge were included. Qualifying exposure required at least 28 cumulative prescription days during the first 6 months after discharge. Follow-up began at the 6-month landmark and continued through December 31, 2024. Associations were estimated using stabilized inverse probability of treatment weighting; propensity score matching served as a sensitivity analysis. Results: Among 4,428 patients, 3,164 received qualifying HF pharmacotherapy and 1,264 did not. Use shifted from angiotensin-converting enzyme inhibitors and digoxin toward angiotensin receptor blockers, beta-blockers, sodium-glucose cotransporter 2 inhibitors, and ivabradine. HF medication use was associated with lower all-cause mortality (HR, 0.57; 95% CI, 0.51-0.65), the composite of cardiovascular death or HF hospitalization (HR, 0.77; 95% CI, 0.65-0.92), and cardiovascular death (HR, 0.65; 95% CI, 0.53-0.79). Renin-angiotensin system inhibitors and beta-blockers were each associated with lower mortality (HR, 0.69; 95% CI, 0.61-0.78). Sensitivity analyses were consistent. Conclusion: Among 6-month survivors of cardiogenic ECMO, a high-risk and clinically unique population often excluded from HF trials, post-discharge HF pharmacotherapy was associated with lower long-term mortality. These findings support structured cardiovascular reassessment and individualized HF medication review after ECMO.